Medical Male Circumcision and Associations Among Sexually Transmitted Infections Service Attendees
Medical male circumcision (MMC) is a proven intervention for preventing HIV acquisition among males. We describe the circumcision status, eligibility for MMC referral and associations with HIV positivity among symptomatic males attending sexually transmitted infections (STI) services. This study was a secondary analysis of cross-sectional data collected during sentinel surveillance for STI aetiologies. In the sentinel surveillance conducted at primary care facilities located in six South African provinces, an anonymous questionnaire was administered followed by collection of appropriate genital and blood specimens for laboratory testing including HIV, rapid plasma reagin (RPR) and HSV-2 serological testing. During analysis, multivariable logistic regression was used to determine association between prevalent HIV infection and male circumcision among males who were HSV-2 AND/OR RPR serology positive and among those who were negative. A total of 847 males were included the analysis, among whom the median age was 28 years (IQR 24–32 years) with 26.3% aged < 25 years. Of these, 166 (19.6%) were medically circumcised, 350 (41.4%) traditionally circumcised while 324 (39%) were not circumcised. The yield of assessment for MMC referral was 27.7%. Overall HIV positivity was 23.1%. Compared to no circumcision, MMC had a statistically insignificant 62% lower odds of being HIV positive –among males who were HSV-2 and RPR negative- adjusted odds ratio [aOR] 0.38 [95% confidence interval (CI) 0.12–1.18], p = 0.094. Among those HSV-2 AND/OR RPR positive, MMC had a statistically insignificant 26% lower odds of being HIV positive- aOR 0.74 (95% CI 0.41–1.36), p = 0.334. In both groups HIV positivity increased with age but was positively associated with condom use at last sexual encounter [aOR 3.41 (95% CI 1.43–8.15)] and previous treatment for an STI syndrome [aOR 3.81 (95% CI 1.60–9.05)] among those HSV-2 and RPR negative. High HIV positivity and high yield of eligibility for VMMC referral among males attending STI services points to the need for better integration of HIV prevention and treatment with STI care.
KeywordsMale circumcision HIV Sexually transmitted infections
The authors would like to acknowledge Dr Vanessa Quan and Dr Linda Erasmus from the NICD GERMS team for operational support during fieldwork, surveillance officers Ms. Valencia Kekana, Mr. Alex Vezi, Ms. Thembisa Makaleng, Ms. Bulele Makaleni, Ms. Badikazi Matiwane and Ms. Khasi Mawasha for data collection, Ms Thabitha Mathega and Ms. Gloria De Gita for data entry and management.
The surveillance activities during which the data were collected and the secondary data analysis described in the manuscript were funded by the National Department of Health in South Africa through core funding to National Institute for Communicable Diseases (NICD). The funder had no role in the design of the study, data collection, data analysis or interpretation. All authors have no conflict of interests to declare.
- 1.Reed JB, Patel RR, Baggaley R. Lessons from a decade of voluntary medical male circumcision implementation and their application to HIV pre-exposure prophylaxis scale up. Int J STD & AIDS. 2018;16:956462418787896.Google Scholar
- 4.Rasheed Z. Male circumcision and human immunodeficiency virus infection: an update on randomized controlled trials and molecular evidences. Int J Health Sci. 2018;12(1):1–3.Google Scholar
- 11.Auvert B, Sobngwi-Tambekou J, Cutler E, Nieuwoudt M, Lissouba P, Puren A, et al. Effect of male circumcision on the prevalence of high-risk human papillomavirus in young men: results of a randomized controlled trial conducted in Orange Farm, South Africa. J Infect Dis. 2009;199(1):14–9.CrossRefGoogle Scholar
- 15.Davis S, Toledo C, Lewis L, Maughan-Brown B, Ayalew K, Kharsany ABM. Does voluntary medical male circumcision protect against sexually transmitted infections among men and women in real-world scale-up settings? Findings of a household survey in KwaZulu-Natal, South Africa. BMJ Glob Health. 2019;4(3):e001389.CrossRefGoogle Scholar
- 19.Morris BJ, Hankins CA, Tobian AA, Krieger JN, Klausner JD. Does male circumcision protect against sexually transmitted infections? Arguments and meta-analyses to the contrary fail to withstand scrutiny. ISRN Urol. 2014;13(2014):684706.Google Scholar
- 20.Davis SM, Hines JZ, Habel M, Grund JM, Ridzon R, Baack B, et al. Progress in voluntary medical male circumcision for HIV prevention supported by the US President’s Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data. BMJ Open. 2018;8(8):e021835.CrossRefGoogle Scholar
- 21.UNAIDS. Joint strategic action framework to accelerate the scale-up of voluntary medical male circumcision for HIV prevention in Eastern and Southern Africa, 2012–2016. Geneva: WHO; 2012.Google Scholar
- 22.World Health Organisation. A framework for voluntary medical male circumcision: effective HIV prevention and a gateway to improved adolescent boys’ & men’s health in Eastern and Southern Africa by 2021. Geneva: WHO; 2016.Google Scholar
- 23.South African National AIDS Council. Enhanced progress report: National Strategic Plan on HIV, STIs and TB (2011–2016). Hatfield: South African National AIDS Council; 2012.Google Scholar
- 24.Marshall E, Rain-Taljaard R, Tsepe M, Monkwe C, Hlatswayo F, Tshabalala S, et al. Sequential cross-sectional surveys in orange farm, a township of South Africa, revealed a constant low voluntary medical male circumcision uptake among adults despite demand creation campaigns and high acceptability. PLoS ONE. 2016;11(7):e0158675.CrossRefGoogle Scholar
- 25.Marshall E, Rain-Taljaard R, Tsepe M, Monkwe C, Taljaard D, Hlatswayo F, et al. Obtaining a male circumcision prevalence rate of 80% among adults in a short time: an observational prospective intervention study in the orange farm township of South Africa. Medicine. 2017;96(4):e5328.CrossRefGoogle Scholar
- 27.World Health Organization. Republic of South Africa. National Department of Health. Sexually transmitted infections management guidelines. Geneva: WHO; 2015.Google Scholar
- 31.Kufa T, Maseko VD, Nhlapo D, Radebe F, Puren A, Kularatne RS. Knowledge of HIV status and antiretroviral therapy use among sexually transmitted infections service attendees and the case for improving the integration of services in South Africa: a cross sectional study. Medicine. 2018;97(39):e12575.CrossRefGoogle Scholar
- 32.Human Sciences Research Council (2018) The fifth South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2017- HIV Impact Assessment Summary. PretoriaGoogle Scholar